Expanding Your Horizons Registration Form

Parent / Guardian Name

Address

City | State | Zip

Phone #

Daughter's Name

Age

School

Grade

Yes - There will be more than one child attending.

Child Name

Age

School

Grade

Child Name

Age

School

Grade

In case of illness or emergency, I understand that every effort will be made to contact emergency contact listed below. If no contact can be made, I hereby give authorization to the above stated organizations to seek medical treatment and if needed arrange for transportation.

My daughter/dependent may participate in photographs, video tapes and/or audio recordings for Girls Inc. at YWCA Syracuse & Onondaga County. I understand that such items shall be the property of the aforementioned programs.

I understand that a healthy snack will be provided. If my child has food allergies or specific needs, I am responsible for providing an appropriate snack.

I understand and give permission for all the above.

Signature | Date

Please describe any special needs you or your daughter may have such as physical limitations, food allergies, medical or health problems that we may accommodate.

Emergency Contact Name

Emergency Contact Phone #

Relationship

Emergency Contact Name

Emergency Contact Phone #

Relationship

Total # of Household Adults

Your Relationship to the Children:

Total # of Household Children

Of these, how many live full-time in the household?

Combined Family / Household Income:

Support

Child's Race

American Indian or Alaska Native

Asian

Black or African American

White

Native Hawaiian or Other Pacific Islander

Multi-Racial

Other

Check One:

Hispanic

Non-Hispanic

Is English a second language for any of the children?

Yes - English is their second language.

No - English is not their second language.

If yes, what is their primary language?

Girls Profile: Which Girls Inc. Programs have you attended?

Afterschool Program

Winter / Spring / Summer Breaks (Camp Discovery, DREAMBuildHer)

Events (EYH, Hoops & Dreams)

Other

None

I would like to learn more about Girls Inc. at the YWCA upcoming events and programs.

Phone #

EYH Registration Form